Print Name
(Check those requested)
——	Outpatient consultations
——	Inpatient consultations
——	Pediatric acupuncture (0–17 years old)
——	Adult acupuncture (≥18 years old)
——	Pregnancy, labor and delivery
——	Access to and documentation in medical record
——	Performance of traditional Chinese physical diagnosis and assessment
——	Placement of acupuncture needles
——	Stimulation of acupuncture needles manually, electrically, or thermally
——	Ear acupuncture
——	Noninvasive modalities including traditional Asian therapeutic massage and cupping
Signature of Applicant	Date
Signature of Department Chair	Date